Mapping Evidence in Teaching Palliative Care in Undergraduate Curriculum of Healthcare Professionals Qualification: A Systematic Scoping Review Protocol

Background Clinical Practice Guidelines recommend interprofessional collaboration in palliative care. However, healthcare profession educators lack clear curricular guidance, particularly for undergraduate programs, to adequately train future professionals for effective participation in such teams. Objective This systematic scoping review protocol aims to address this gap by: (i) mapping evidence on key characteristics of teaching palliative and end-of-life (EOL) care to undergraduate healthcare and social care students, and (ii) identifying the nature and effectiveness of educational interventions for improving palliative care education in the undergraduate curriculum. Methods and Expected Outputs The protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol Extension for Scoping Reviews (PRISMA-P-ScR) guidelines, while the proposed systematic scoping review study will be conducted based on methods and steps identified by Arksey and O’Malley and experts in the field. We will conduct systematic searches across five EBSCOhost databases using relevant search terms. Additionally, a limited grey literature search will be conducted on the first 100 results of Google Scholar and Open-Grey. The selection process will follow PRISMA-Extension for Scoping Reviews. Two independent reviewers will screen titles and abstracts for eligibility. Data extraction will be done on standardized forms in duplicate with cross-checking by a third reviewer. Braun and Clarke’s thematic analysis approach, combining thematic and directed content analysis, will be employed for analysis. Intervention effectiveness will be narratively summarized based on the TIDieR checklist. Meta-analysis will be considered if applicable and data is homogeneous. Discussion Palliative care education (PCE) is a crucial element of undergraduate health professions education. This study’s findings may aid educators in fostering optimal learning among healthcare students, who can then positively influence community health outcomes. Ethics and dissemination The protocol was submitted for ethical clearance to the University of KwaZulu-Natal’s Biomedical Research Ethics Committee and granted exemption from ethics review (00024289). We will disseminate findings through scientific journal publication and by sharing a summary with relevant institutions and attendees at health promotion and interprofessional education conferences.

those who could bene t from palliative care actually end up receiving it, highlighting a signi cant gap in access, particularly for LMIC populations. 1 Remission and survival rates for palliative care patients in most African countries are adversely affected by late detection, diagnosis, limited training of health care providers, and lack of resources for treatment and palliative care services in health facilities. 2,3 th Africa's unique disease burden, characterised by a high prevalence of HIV, tuberculosis (TB), and noncommunicable diseases (NCDs) like cancers and injuries, intensi es the existing gap in palliative care services.This is particularly true for infectious diseases like TB and HIV, which are known to cause signi cant suffering in LMICs. 4his underscores the critical necessity for comprehensive and integrated approaches to palliative and end-of-life care education and service provision, especially in regions facing such signi cant health challenges.

Health Policy Context of the study: Global, Continental and National
The pressing need for palliative care in Africa is further highlighted by the World Health Assembly Resolution 67.19 passed in 2014.This resolution speci cally called on member states to integrate palliative care into comprehensive care throughout a person's life. 5Request number four of the resolution explicitly addresses education and training, urging countries to include palliative care as a standard part of healthcare professional education and training.This includes integrating basic and continuing education on palliative care into undergraduate medical and nursing programs, as well as in-service training for care providers at the primary care level, including doctors, nurses, primary care workers (such as community health workers), spiritual caregivers (those who provide emotional and religious support to patients and families), and social workers.However, despite international recognition and clear steps outlined in resolutions like the World Health Assembly Resolution 67. 19, translating the de nition of palliative care into accessible services for Africans remains a challenge.This disconnect between the urgent demand for palliative care in regions such as South Africa and the insu cient advancements made in establishing comprehensive educational and training initiatives, as advocated by international resolutions underscores the need for stronger implementation efforts to ensure that palliative care becomes a true pillar of Universal Health Coverage (UHC) on the continent.
Countries can not meet the United Nations Sustainable Development Goal Three, speci cally Target 3.8, without including palliative care and pain relief. 6South Africa has adopted the policy of National Health Insurance intended to promote access to promotive, preventive, curative, rehabilitative and palliative care services of su cient quality to be effective while not exposing citizens to nancial hardship. 7lliative Care in Undergraduate Health Professions Education.
A scoping review was conducted to examine the provision of Palliative Care services in Africa from 2005 to 2016. 4 The study followed the guidelines set by the World Health Organisation (WHO) for the public health strategy of palliative care, 8 which include the implementation of services, educational initiatives, policy development, medicine availability, and professional engagement.The review ndings revealed a signi cant presence of these services in Kenya, South Africa, and Uganda. 4Stand-alone palliative care policies exist in Malawi, Mozambique, Rwanda, Swaziland, Tanzania, and Zimbabwe. 4e South African National Department of Health adopted the National Policy Framework and Strategy on Palliative Care 2017-2022 to promote the development and delivery of Palliative Care services. 7However, despite these efforts, the lack of access to Palliative Care services on the African continent was further emphasised by the Lancet Commission Report, which provided recommendations concerning Human Resources in this context: "Establish palliative care as a recognised medical and nursing speciality; Make general palliative care and pain relief competencies a mandatory component of all medicine, nursing, psychology, social work, and pharmacy undergraduate curricula; Require that all health and other professionals involved in caring for patients with serious, complex, or life-threatening health conditions receive basic training in palliative care and pain relief." 3 Current undergraduate health professional curricula throughout Africa have elements of Palliative Care education that are poorly quanti ed despite palliative care being recognised as an emerging discipline in health care.Therefore, there is an urgent need to review and strengthen curricula to provide an inter-professional approach to palliative care education for the African health professional, allowing future t professionals to competently deliver on the growing Palliative Care needs of the continent.This will lay the foundation for a sustainable, high-quality and accessible palliative care system integrated into primary health care, community and home-based care, and supporting care providers such as family and community volunteers. 9e rationale for the study While accreditation bodies have mandated teaching basic palliative and end-of-life (EOL) care across healthcare professions training curricula, 9 there has been limited guidance for educators on what or how to teach and evaluate students' competence, particularly in the undergraduate curriculum for HCP quali cation.Moreover, there is a lack of extensive evidence regarding the nature and effectiveness of educational interventions to improve palliative care education and whether these interventions result in positive outcomes.
A preliminary systematic search was performed using the EBSCOhost platform, searching two databases, Medline and CINAHL, and nding no scoping reviews for palliative care education and training in the undergraduate curriculum for HCP quali cation.In addition, the two international perspective registers of systematic and scoping review databases, PROSPERO and the Open Science Framework (OSF), were searched respectively, and no similar review protocols were identi ed.Therefore, due to this limited evidence, our aims were broad, which was more suited for a scoping review rather than a systematic review, which would be, to sum up, the best available research on palliative care education (PCE) across the undergraduate curriculum for HCP quali cation.

Aim
This scoping review aims to systematically map the research done in palliative care education (PCE), as well as to identify the nature and effectiveness of educational interventions to improve palliative and end-of-life (EOL) care education across the undergraduate curriculum for HCPs quali cations.

Objectives
To systematically map the scope of available published knowledge about teaching palliative and EOL care across the undergraduate curriculum for HCP quali cation.
Sub-objectives 1.To identify studies that have used educational and training interventions for palliative and end-of-life (EOL) care teaching across HCP training curricula; 2. To critically appraise and identify curricular components of effective interventions in the undergraduate curriculum for HCP quali cation; and 3. To use this critically appraised evidence base to inform the design of palliative and end-of-life (EOL) care teaching across HCP training curricula.

METHODOLOGY Study Design -Protocol and registration
This scoping review protocol is part of a more extensive study [Details of the bigger project goes here], and the protocol for the complete review is available in the PROSPERO data repository registries -ID CRD42023481892 https://www.crd.york.ac.uk/prospero/export_details_pdf.php.
As part of the more extensive study, a scoping review was chosen as the best method to systematically synthesise qualitative and quantitative evidence on the nature and effectiveness of currently available educational interventions to improve palliative care education for health and social care professionals in the undergraduate curriculum.The protocol for the scoping review was developed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for a scoping review (PRISMA-P-ScR), which permitted the forwarding of a six-step scoping review protocol (see Supplementary Appendix for the completed PRISMA-P Checklist). 10 The proposed comprehensive systematic scoping review of the literature will be conducted according to the Levac et al. ( 2010) adaptation to Arksey and O'Malley (2005) framework for scoping review methods and experts in the eld. 11,12 he review ndings will be reported per the PRISMA 2020 statement -an updated procedure for reporting review studies (see Fig. 1 for the PRISMA-2020 owchart). 13- Step 1: Identifying the review question As an integral component of the framework's preliminary phase, the research team received guidance from the expert team in formulating comprehensive and speci c research questions.Additionally, the study protocol's design, the selection of search terms for the literature review, and the identi cation of relevant databases were established through a collaborative process involving iterative consultations with our research team, key informants possessing expertise in curricular design, implementation, and assessment of healthcare professional quali cations in both general and speci c contexts related to palliative and end-of-life care.Furthermore, the input of an experienced medical librarian was sought in this process.
To determine whether the research question quali ed for a scoping review project, we utilised the PICO (participants; interventions; comparator; outcomes) nomenclature framework recommended by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis: 2020 Edition (Fig. 2). 14e main research question that the proposed scoping review will address: What is the nature and effectiveness of teaching palliative and end-of-life (EOL) care to students in the undergraduate health and social care professionals quali cations curriculum?
More speci cally, the scoping review seeks to address the following research sub-questions: 1. What is the evidence on the nature of educational interventions to improve palliative and end-of-life (EOL) care teaching in the undergraduate curriculum for health and social care professionals quali cations? 2. What is the effectiveness of educational interventions to improve palliative and end-of-life (EOL) care teaching in the undergraduate curriculum for health and social care professionals quali cations?
The eligibility criteria for including studies in this review in order to answer the aforementioned questions are based on the relevant components of the PICOd-T (Study Design -Time) framework and the research question.Thus, the PICOd-T framework is employed to ensure that the boundaries of the proposed scoping review research question are clearly de ned.
The eligible studies will be included once they have been evaluated independently, reproducibly, and systematically by two reviewers.For studies to be considered eligible, studies must provide evidence of one of the factors listed in Table 3.A third reviewer will resolve disagreements between the two reviewers; reviewers will also pilot-test the inclusion/exclusion criteria to reach a consensus before beginning the study selection process (Step 3: Study selection and eligibility screening).
Step 2: Identifying relevant studies -Search Strategy and Data Sources The systematic, comprehensive, and reproducible searches to identify relevant studies will initially be conducted via electronic search sources -searching reputable bibliographic databases and indexing services (and platforms)followed by searches of supplementary information sources to capture primary studies addressing the main review question.With the assistance of a professional medical librarian, the rst author will conduct all direct electronic and supplementary information source systematic searches, using a pre-de ned and piloted search strategy (see Table 1), to capture both published and unpublished (grey) literature to be screened for eligibility for inclusion in this review.

Search Strategy
The rst author, a medical librarian and subject specialist with experience in designing, implementing, and assessing HCP quali cations in general and in the palliative and EOL care domain, co-developed the comprehensive search strategy (see Table 1 for details of the search strategy metrics).All authors were given an equal opportunity to review the draft to ensure the correct use of indexing terminology and Medical Subject Headings (MeSH) descriptors before it was pilot-tested on a subset of records from the PubMed database (see Table 1 pilot test results).
In accordance with the approach of Bethel et al., (2021), a search summary table (SST) will be used to report on the performance of the search strategy in effective searching databases.The SST is a viable and reproducible method for reporting and evaluating the search strategy's effectiveness (see Table 2 for the example of the SST metrics that will be used for this purpose). 15ta Sources

Electronic search sources
The systematic and comprehensive searches will be conducted from the following electronic databases to source articles published on the topic of teaching palliative and end-of-life (EOL) care to students in the undergraduate curriculum of HCPs quali cation, using the pilot-tested search strategy: WEB of Science, PubMed, and EBSCOHost Web (Academic Search Complete, PyscInfo, MEDLINE with Full Text, and Health Source: (Nursing/Academic Edition)).Furthermore, evidence on palliative care teaching interventions will be sourced from the South African National Clinical Trial Register and the ISRCTN registry.The mentioned databases will be searched from their inception to the present, regardless of the publication language.This procedure aims to obtain as many articles as possible from electronic search sources and to ensure that all relevant articles or reports are captured before the study selection and eligibility screening process begins.

Searching other resources -supplementary information search
In addition, supplementary search methods will include hand-searching of relevant journals, reference lists of identi ed peer-reviewed articles and grey literature, and as well as forward and backwards citation chasing.The reviewers will further browse through the link entitled "Related Articles" option, which searches for similar citations using an intricate algorithm that scans titles, abstracts, and MeSH terms to detect more studies (Table 3).Systematic reviews and other review papers are not eligible for inclusion; however, reference lists of relevant reviews, preprints, and conference abstracts will be screened for more relevant primary studies not captured by the search strategy.Furthermore, the appropriate trial publications reference lists will be checked for unidenti ed randomised clinical trials.

The systematic search management
The SST will also be used to present and keep records of the systematic searches retrieved information, such as the summative metrics of effective searching suggested by Cooper et al., (2018), and additional metrics providing further useful search-related information for the librarian or information specialist. 16e SST will be completed in two stages.In stage one, all the references that the search strategy retrieves from each electronic database, including all duplicates, will be exported to EndNote X9 (version 19.1.0.12691) -a reference management software, which will be used to create a virtual library (Thomson Reuters, Stamford, CT, USA). 17Every record in the virtual library will be given a code for the database name where the record was found.
Stage two involves re-running the searches in the databases where most of the included references were found to determine whether references not found during the original search were in the database and, if so, whether the search strategy retrieved them.

Step 3: Study selection and eligibility screening
The study selection and eligibility screening method is multi-step and involves two reviewers.The eligibility screening approach for eligible articles will be carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria, as represented in the PRISMA 2020 Flow Diagram Fig. 1.
First, two reviewers will screen the title and abstracts for relevance independently and in duplicate, and articles that pass initial screening by either reviewer will undergo full-text review independently and in duplicate by the same two reviewers.Standardised, pilot-tested eligibility forms will be used for both title and abstract screening and for fulltext review (see Supplementary Appendix for the completed screening tool).
Disagreements about study eligibility will be resolved through consensus discussion or will be resolved by a third reviewer in the case of ongoing disagreement.Kappa statistics will be calculated to assess the inter-rater reliability of full-text review, using Cohen's Kappa coe cient (κ) statistic on Stata 13.0SE (StataCorp College Station, TX, USA), a robust statistic used for inter-rater reliability testing. 18ep 4: Data extraction/ or collection process A standardised data extraction form informed by the template for intervention description and replication (TIDieR) checklist and guide for describing interventions will be created to capture relevant information from the included studies (see Supplementary Appendix for the data extraction form). 19The form will consist of elds for study characteristics, participant demographics, teaching/ or communication strategies employed, outcome measures, and key ndings Two independent reviewers will extract data from the included studies using the standardised data extraction form to detect inter-rater errors and decrease data errors and bias.The reviewers will extract data from the included articles independently and in duplicate.A third reviewer will verify the data related to study characteristics, such as publication information, study dates, population characteristics, interventions, outcomes, and study methods, which are required to assess the risk of bias.
In the meta-analysis, the nature of the data, such as continuous outcomes (mean differences or standardised mean differences) or dichotomous outcomes (odds ratios or risk ratios (ORs)) will be calculated if necessary, and if the data is available, only measures most adjusted for one or more sets of potential confounders such as sociodemographic and lifestyle factors will be extracted by the two reviewers to reduce confounding and measurement errors and to ensure consistency across studies and reduce bias.

Requests for missing data
Missing data will be identi ed and recorded within the review.Where papers provide insu cient details about the intervention, such as what is delivered and by whom, an effort would be made to contact the authors to obtain previously unpublished information and clarify any missing data.In cases of non-response or inadequate clarity from contacted authors (i.e.retrieval of missing data is not possible), that study/outcome will be eliminated from the review.
Step 5: Assessment of study methodological quality, risk of bias, and the certainty of evidence The methodological quality and risk of bias of each included study will be assessed by two reviewers independently, using appropriate methodological quality assessment tools depending on the design of the included studies using the guidance produced by the NHS Centre for Reviews and Dissemination and the Cochrane Collaboration. 20,21 ols to assess the methodological quality As recommended, the MERSQI (Medical Education Research Study Quality Instrument) Scale and Newcastle-Ottawa Scale Education (NOS-E) [19, 20] will be used to determine the methodological quality of the included studies. 22,23  two instruments will be used as they assess different aspects of quality and risk of bias, acting in a complementary fashion.As described in previous studies, a score above the sample median MERSQI score (12.5)   and NOS-E score (2.5) will be considered the threshold for high methodological quality. 22rthermore, the risk of bias for RCTs will be assessed using the Cochrane risk of bias tool, which will take into account random sequence generation, allocation concealment, participant and personnel blinding, insu cient outcome data, and selective reporting.Each domain will be evaluated independently by both reviewers and classi ed as 'high,' 'low,' or regarding bias.Studies will be considered to be at an overall 'high' risk of bias if they are judged to be at 'high' risk of bias in any domain, 'uncertain' risk of bias if they are judged to be at an uncertain risk of bias in any one domain, with no domains at high risk of bias, and an overall 'low' risk of bias if they are not judged to be at 'high' or 'uncertain' risk of bias in any domain.All risk of bias assessment will be judged at the outcome level.
Tools to assess the risk of bias (or publication bias) Publication bias will be assessed using visual inspection of funnel plots, where su cient numbers of studies will exist to permit interpretation. 24ols to the certainty of evidence (quality of evidence/ the strength of the body of evidence) The overall quality of evidence (or certainty in the ndings) for each outcome obtained will be evaluated using the ve GRADE principles (trial bias risk, consistency of effect, imprecision, indirectness, and publication bias).The completed GRADE checklist and reasons for up-or down-grading assess the quality of a body of evidence based on study methodological quality, results from sensitivity analysis, and by downgrading and upgrading the baseline quality score according to the domains speci ed in the GRADE guidelines. 25We will generate a table that summarises our ndings using GradePRO software. 26ep 7: Collating, summarising, and reporting the results Systematic scoping reviews provide executive overview of current evidence by answering broad questions. 27hus, following the completion of the data extraction step, we will generate a comprehensive summary of the data extracted from the included studies.The summary will consist of two key presentation components: 1. Numerical presentation: We will create a compiled ndings table that provides a descriptive overview of the key pre-speci ed study outcomes and type of included studies, as depicted in Fig. 2. Additionally, we will employ an interactive web-based graphic design tool, speci cally Canva version 2.93.0, to generate a world map. 28This map will help visualise the geographical distribution of the summary of the included studies, offering insight into global patterns.2. Narrative presentation: To ensure a holistic analysis, we will synthesise the essential characteristics of all the included studies.We will archive this by documenting the structure of the intervention of interest -all educational interventions used to teach palliative and end-of-life (EOL) care education to health and social care professionals in the undergraduate curriculum -will be captured by recording pedagogy, course content and Furthermore, a key area of work that will commence as part of the project's more extensive study (and is likely to outlive the lifespan of the project) is to engage with key stakeholders regarding the inclusion of palliative and EOL care into all undergraduate curricula for health and social care professionals quali cation programs in Africa.It is envisaged that a consensus statement will be developed and shared in a range of forums, in particular the African Palliative Care Association, Africa-wide family medicine structures such as Primafamed and WONCA Africa as well as AFREhealth, in which they will be consulted, thus providing valuable insights beyond what has been captured through scoping review project.A limitation of this study is that only peer-reviewed literature in English will be included, which will limit the scope of this review to articles published in English-speaking countries or those published in English.

Figures Figure 1 Preferred
Figures A strength of this study is that it will apply a broad review of multidisciplinary databases covering Public Environmental Occupational Health, Nursing, Health Care Sciences Services, Medicine General Internal, Education Scienti c Disciplines, Educational Research, Social Sciences Interdisciplinary and other Web of Science Core Collection Citation Topic providing a comprehensive assessment of published literature on courses designed on these subjects.See the Supplementary Appendix le for the search strategy pilot results analysis completed for the Web of Science database report.

Table 1 :
Search strategies with MeSH descriptors and truncation, with pilot-test results from PubMed, will be adapted for other databases.Medical Doctors OR Nursing Professionals OR Midwifery Professionals OR Midwives OR Dentists OR "Dieti*" OR "medical technology*" OR Pharmacists OR Dentist OR dental assistant OR emergency care practitioner OR emergency care assistant OR emergency care technician OR Emergency Medical Technician OR Occupational Therapist OR Physiotherapy Therapist OR Dialysis Technician OR Speech Language Pathologist OR Audiologist OR Physiotherapy OR Optometrist OR Healthcare Chaplain OR General practitioner OR Primary care physician OR Community Health practitioner OR Pharmacy technician OR Dental Therapy OR Oral Hygiene OR Epidemiologist OR Public Health Nurse OR Radiologist OR Clinical Technology OR health profession* OR "Healthcare profession*"AND Palliative and End-of-Life (EOL) Care:care" OR "dying with dignity" OR "pain management" OR hospice * OR grief * OR bereavement * OR "Terminal care" OR Hospic* OR "Hospice Care" OR "palliative care education" OR education * AND The Comparators (The Standard Teaching) and Outcomes (Any assessment of the "impact.") is as reported in the study.Free text terms / natural language terms: (synonyms, US terminology, laymen's terms, acronyms/abbreviations, drug brands, more narrow search terms) Consider: phrase searching, proximity operators, truncation, wildcards, eld quali cation (e.g.textword).Controlled vocabulary terms / Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings

Table 2 :
The Search Summary Table (SST), will be used to report on the search strategy performance.CriteriaInclusions Exclusions to establish agreement prior to commencing the study selection process.